Immediate Postoperative Management of Cardiac Surgery Patients

Cardiac surgery is quite common in the United States. Outcomes after cardiac surgery are not only dependent on how the surgery went and how the anesthesia care was provided intraoperatively but also on the optimal management in the postoperative critical care setting. It is of paramount importance that the cardiac intensivist has a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. Most preventable deaths after cardiac surgery have been linked to postoperative problems in the intensive care unit (ICU).(1,2) Failure to recognize and rescue a patient from potentially reversible complications is a cause of perioperative morbidity and mortality. Patients who undergo cardiac surgery often present with multiple rapidly changing clinical problems; they are initially unstable with extremely fluid and dynamic clinical status. Postoperative care of these patients requires knowledge of general fundamental concepts of patient care as well as concepts unique to this set of patients. The initial management of these patients as they return from the operating room is critical, because clinical errors at this time can have far-reaching implications. The initial management should begin even before the patient arrives in the cardiovascular intensive care unit (CVICU). It is vital that the cardiac intensivist reviews the chart and notes the type of surgery, indications, preoperative hemodynamic data, comorbid conditions, medications, and allergies. Upon the patient’s arrival in the CVICU, a careful systematic assessment of the patient begins with obtaining a comprehensive handoff from the surgical and anesthesia team. The cardiac intensivist should ascertain what procedure was done in the operating room and inquire as to any intraoperative events that might impact the patient’s postoperative course. Then, they should physically examine the patient as part of this initial evaluation. During the initial assessment, the intensivist should avoid focusing on any one issue and attempt to get a global picture of the patient’s clinical status. A thorough knowledge of the specific monitoring and drug delivery lines is imperative, as is knowledge of where the drains are placed. Once the initial assessment is complete, specific issues can be identified, prioritized, and addressed.(3,4)